A patient was admitted to the surgical unit after undergoing a right modified radical mastectomy. Which of the following should the nurse include in the patient's care plan?

Take the blood pressure in the left arm.
While assessing the surgical dressing, check the right posterior axilla.

Explanation

• After a mastectomy, if there is drainage or bleeding from the surgical site it can seep down due to gravity and may soak the posterior axillary portion of the dressing. The nurse must, therefore, check the right posterior axilla to detect bleeding.

• Position the patient in semi-Fowler’s position with the arm supported on pillows to decrease edema. Position the patient on her back or unaffected side, never on the affected side as this could increase edema and cause pain.

• Blood pressure, venipunctures, and IV sites must not involve the use of the affected arm (this is for the patient's lifetime). The lymph nodes on the affected side may have been removed during the surgery and the site will be more prone to develop lymphedema after any injury (venipuncture/IV) or trauma to the arm because there are fewer lymph nodes on that side to help drain fluid and fight infections.

• Resting the arm of the affected side on a pillow over the head after a mastectomy would be discouraged in the early post-operative recovery stage because it would put strain on the incision site and cause pain.

Visit our website for other NCLEX topics now!